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Malignancy in the chronic gastric ulcer
MALIGNANCY IN THE CHRONIC GASTRIC ULCER* W. J. MERLE SCOTT, M.D. AND G. BURROUGHS MIDER, M.D. Associate Professor of Surgery, University of Rochester SchooI of Medicine and Dentistry ROCHESTER,
W
HEN Cruveilhierl. estabhshed tric uIcer as a pathoIogic cIinica1 entity separate from
Fellow in Surgery, University of Rochester Medicine and Dentistry NEW
School of
YORK
differentiated from chronic gastric ulcer certain radioIogic by this means. AIso features of some uIcers are rather patho-
gasand car-
FIG. I. Meniscus sign. Note the Iarge crescentic encroachment on the lumen of the stomach about the centra1 ukeration. This Iesion was a maIignant uIcer occurring on the posterior waI1 of the stomach. The meniscus sign is practicaIIy pathognomonic of maIignancy and usuaIIy has to be obtained with the aid of palpation at fluoroscopy. Dotted Iine indicates the extent of the meniscus.
gnomonic. Thus the meniscus formation about an uIcer (Fig. I) signifies malignancy,2 whiIe the formation of an-accessary pocket by the niche (Fig. 2), is fairIy good evidence that the uIcer at least started as a benign one.3 It was hoped at one time that the size of the uIcer, as reveaIed roentgenoIogicaIIy, might be a good index of its character.4 It is true that the majority of uIcers over 2.5 cm. in diameter are maIignant, whiIe most of the smaI1 uIcers (I to 1.5 cm. in diameter) prove to be benign.
cinema of the stomach, he Iaid the foundation for our modern conception of these two conditions. He mentioned the occasiona1 presence of both Iesions in the same the two conditions organ, but thought could always be differentiated grossIy one from the other. Since then the advent of the roentgenographic examination has enormousIy assisted us in the cIinica1 diagnosis. The usua1 types of scirrhous and papiIIary carcinoma of the stomach are easiIy * From the Department
of Surgery,
the UniversityLRY;fester e 42
SchooI of Medicine and Dentistry,
Rochester,
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However, there are so many exceptions to this genera1 ruIe (Fig. 3) that it is aImost vaIueIess as a guide to therapy
in Ulcer
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other hand, if a11 cases of gastric carcinoma with symptomatic or roentgenographic evidence of uIceration were incIuded in the
FIG. 2. An uIcer with an accessory pocket outside the stomach. As a rule such lesions are benign no matter how large the crater, untess definite characteristics of malignancy are present in the stomach wall adjacent to the uker. This enormous ulcer proved to be benign.
in the individua1 case.5 Other factors, such as the age of the patient, the constancy and duration of symptoms, the Iocation of the uIcer, etc., assist from a statistica basis,6,7 but are inadequate in the individua1 instance for making this differentiation. In the century since Cruveilhier’s time, we have Iearned that there is a lesion with a11 the characteristics of the benign uIcer which proves nevertheIess to be maIignant. The exact frequency of this malignant uIcer which cannot be differentiated either by symptoms, by x-ray examination, or at times even by gross examination, wiI1 vary considerabIy in different series, depending partly on the criteria estabIished by the compiIer. Thus, if every uIcer in the stomach is considered a potentially malignant Iesion, then automaticaIIy a11 Iesions which eventuahy prove to be malignant would be segregated as carcinoma suspects and wouId never appear in the statistics of a group of chronic gastric ulcers. On the
group, the percentage of such chronic malignant ulcers wouId be disproportionateiy high. In the record when the diagnosis eventuaIIy proves to be maIignancy, the preliminary diagnosis of gastric uIcer is discarded and the case is cIassified in the diagnostic file as carcinoma of the stomach. Consequently the onIy method of estimating the percentage of cases, which present themseIves as chronic gastric ulcers but eventuaIly prove to be malignant, is by studying the diagnostic data after carefu1 clinica and roentgenographic study but before the fIna pathoIogic evidence is known. It is, in our opinion, a conservative estimate that, when the incidence is determined in this manner, IO to 20 per cent of the chronic uIcers of the stomach without defmite criteria of malignancy prove eventuaIIy to be or to become maIignant. Whether such uIcers are from the first carcinomatous or whether they represent
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a malignant degeneration of a pre-existing benign ulcer has been vigorously debated. This interesting subject has been previousIy
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gastric ulcers there is at present no method of examination, either clinical, chemical or roentgenographic, that will with certainty
FIG. 3. The size of the ulcer crater is no criterion of its malignancy in the individual case. This uIcer on the lesser curvature of the stomach measured 3.8 cm. in diameter. It was resected and proved benign.
FIG. 4. Gastric uIcer Iocated on the Iesser curvature at the incisura angularis. In spite of the immediate compIete relief of symptoms by an ambulatory medical regime, the size of the uIcer was not decreased at the end of three weeks. Hence the Iesion was treated as carcinoma. (Fig. 3 shows the microscopic picture.)
carefuIIy reviewed by one of us. 8 The controversia1 aspects of this question have distracted attention from the important clinica fact; in the majority of chronic
distinguish the mahgnant from Iesions. And yet it is extremeIy to determine this point to give tage of early operation in the
the benign important the advanmalignant
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se. One sohrtion of the probIem proposed is to operate upon al1 cases ’ t1re surgeon ch ronic gastric uIcer. Another method of
in UIcer
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acteristic, coming two to three hours a fter meats and being relieved by soda, though not so much by food. The bouts of pain had re-
FIG. 3. Same case as in Figure 4. Transition in the mucous membrane from reIatively architecture to definite carcinoma at the edge of the ulcer. (X 100.)
handIing this situation is to ignore the danger of malignancy. Neither of these pIans is acceptabIe today, the first because it entaiIs unnecessary surgery in many cases, the second because it takes away the patient’s best chance for a cure. Its exponents claim for gastroscopy that it is a vaIuabIe adjunct in deciding the character of an ulcer. EventuaIIy this direct visua1 inspection may be very heIpfu1 when the uIcer can be seen but it has not yet sufhciently proved itself. The foIIowing case ihustrates the diIemma of the chronic gastric ulcer and the method we have adopted to meet it. C. W. A., a 62 year oId farmer, was referred the out-patient department of the Strong MemoriaI Hospital on January 31, 1934, complaining of attacks of epigastric pain of seven months’ duration. The pain was fairIy charto
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centIy become somewhat more frequent and severe. The patient reported that he did not vomit, but was frequentIy nauseated. He had Iost 15 pounds in weight. On physica examination he appeared rather thin and he had a moderate degree of arteriosclerosis. No masses were paIpabIe in the abdomen, nor was there any tenderness elicited. Examination of the blood and urine proved negative. On gastric anaIysis, he had no free HCI in the fasting sample, but did have thirty minutes after an aIcoho1 test meal. A St001 specimen gave a negative test for occult bIood. On his first visit to the out-patient department a tentative diagnosis of peptic ulcer, unIocaIized, was made from the history and while arrangements for gastrointestinal x-ray studies were being compIeted, he was put upon an ulcer rCgime (ambuIatory smooth), This promptly reIieved his pain and made him quite comfortabIe. The gastrointestina1 series showed
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a fairIy Iarge uIcer nlithe on the Iesser curvature of the stomach just dista1 to the incisura angularis. (Fig. 4.)
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to expIain to him the dangers of the situaltion. With the aid of the brother’s persuasion, the patient fInalIy accepted operation which was
FIG. 6. Carcinoma producing an extensive characteristic fiIIing defect along the greater curvature of the stomach. At the time this x-ray was taken, symptoms were relieved by dietary treatment and the patient gained 25 pounds in weight. The diagnosis was verified later by biopsy of metastases.
As soon as the uIcer was Iocalized in the stomach, he was advised to come into the hospita1 for a period of strict medica rCgime, but, since he had no pain, he refused to foIIow this advice. The importance of repeating the x-ray studies in three weeks time was urged upon him, however. This was done on March 28 and no significant change in the size of the fiIIing defect was found aIthough there had been compIete reIief of symptoms and a gain of IO pounds in weight. As this faiIure of the uIcer to decrease in size placed it in the carcinomasuspect group in spite of the cIinica1 improvement, he was advised to enter the hospital for operation. He refused to accept this advice even on urging. ConsequentIy his brother, a minister, was caIIed from a distance of 400 miIes in order
carried out on ApriI g, 1934. A chronic uIcer was found at the site indicated by the x-ray examination. It was moderateIy indurated but had no characteristics to distinguish it as a malignant uIcer. On microscopic section, however, there was definite infiltration of the ulcer base with carcinomatous ceIIs. (Fig. 5.) Four years after operation this patient is symptom-free without evidence of recurrence. Certain features in the above case emphasize facts of great cIinica1 importance.
In the first pIace, the compIete disappearance of symptoms with a significant gain in weight when the patient is put on a medica rkgime is no evidence whatever
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that the ulcer is benign. In fact, frequentIy the mahgnant gastric Iesion wiI1 respond in this manner even when it presents unmistakable roentgenoIogic evidence of its maIignancy. Figure 6 shows such a frank carcinoma of the stomach producing a Iarge fiIIing defect of the greater curvature. Yet for three months this patient’s symptom of gastric distress was unfortunateIy controIIed by a medica uIcer regime under the care of her IocaI physician whiIe she gained 23 pounds in weight. She was referred for surgery onIy after symptoms had recurred under treatment, a condition which usuaIIy signifies an extension of the maiignant process. Dr. OsIer frequentIy caIIed attention to such temporary improvement on the institution of dietary treatment in gastric carcinoma. In the second pIace, however, the faiIure of the ulcer to decrease significantIy in size after three weeks treatment places it definiteIy as a carcinoma-suspect. Jordan and Laheyg were the first to emphasize the importance of such a response as a criterion of the nature of the ulcer. In our cIinic, a11 gastric uIcers are divided within three weeks into two groups on the basis of their behavior on a strict uIcer regime. lo The first group contains most of the benign uIcers, and is characterized as foIIows: (I) UIcer pain diminishes in the first week. (2) AI1 symptoms and occult bIood in the stool (if present) disappear within two weeks. (3) There is a signijcant decrease in the size of the ulcer niche (at least one-third of its cross-sectional area) within three weeks. If any of these three conditions is not fulfiIIed, the uIcer immediately falIs into the second or carcinomasuspect group. This Iatter contains almost a11 of the carcinomatous ulcers, together with a minority of benign uIcers, which are particuIarIy recaIcitrant to medica treatment (usuaIIy due to an adherence of the uIcer base to the pancreas or Iiver). As previousIy emphasized, malignant uIcers not infrequentIy respond to treatment with symptomatic relief; a few of them wiI1 even give roentgenographic
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evidence of heaIing at the end of three weeks. ConsequentIy it cannot be inferred that the uIcers in the first group are a11 benign uIcers, but onIy that conservative treatment shouId be continued. The ulcer, however, shouid be foIIowed roentgenographicaIIy at intervars of four to six weeks until the niche has compIeteIy disappeared. Then, if symptoms recur on treatment, or if the uIcer after decreasing in size becomes stationary or particuIarIy if it begins to enIarge, this immediateIy transfers the case to the second group and prompt operation becomes imperative. The importance of following this ruie is iIIustrated by the foIIowing case : P. W., a 40 year old man with a somewhat vague previous history of uIcer was admitted with a perforation on December 12, 193 I. It was thought before the first operation that the uIcer was probabIy duodena1, but a free perforation I cm. in diameter without any unusua1 induration about it, was found on the Iesser curvature of the stomach about 2.5 cm. from the pylorus. This was cIosed by inversion and the patient had an uninterrupted convaIescence with symptomatic reIief for about two years. He then had a recurrence of some distress but not sufficient to bring him back to the cIinic unti1 about six weeks Iater when he had a major hemorrhage. presenting cIinicaIIy as meIena with a drop in the red count to 3,500,000. In view of the recurrence of symptoms, however, as soon as he had regenerated a fair proportion of the Iost bIood, operation was carried out on the patient as a carcinoma-suspect. The site of the previous uIcer on the Iesser curvature couId be identified by two encysted bIack siIk sutures on the peritonea1 surface and the lesion was dire&y contiguous to this scar on the posterior surface of the stomach. Due to the extensive induration of the Iesion, it was thought to be a maIignant ulcer and microscopic examination proved it to be such. A subtota1 gastrectomy was carried out which gave the patient compIete reIief for two years, after which he deveIoped metastases to the spine. This is the onIy case that we have had in which free perforation of a non-indurated gastric uIcer has eventuated in a carcinomatous ulcer. Graham” records a most unusua1 case in which he folIowed the heaIing of an uIcer
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niche to complete disappearance with the subsequent recurrence of a malignant ulcer at that site. While such extreme exampIes as these cases are unusua1, the recurrence of symptoms from a gastric uIcer whiIe the patient is on an adequate conservative regime is aIways an ominous sign and at once puts the uIcer in the carcinomasuspect group. The fIna feature, and an extremeIy important one in the management of these uIcers, is the type of surgery to be empIoyed in the second group, which does not respond with satisfactory heaIing to the therapeutic test. Many surgeons fee1 that a IocaI excision of the Iesion (usuaIIy with gastroenterostomy) is satisfactory. Indeed, this is probabIy the prevaiIing opinion, even being heId by some Ieading surgica1 authorities.12q13 However, we are convinced both on a priori reasoning and on the basis of the experience of ourseIves and others that this pIan is absoIuteIy wrong if the patient is a fairIy good surgica1 risk. The majority of the benign gastric uIcers by the pIan outIined never require surgica1 intervention, and most of the group seIected in this manner by their response to the therapeutic test prove to be maIignant. It is impossible to teI1 at operation in this seIected group which wil1 prove to be benign and which maIignant. ConsequentIy we fee1 that the only rationa pIan is to treat the uIcers of this group at operation exactIy as the surgeon wouId if he knew the pathoIogic section showed maIignancy aIready at hand. This means, in our opinion, carrying out subtota1 gastrectomy, incIuding the Iymph gIand-bearing areas aIong the Ieft gastric artery, in the paraduodena1 region, and of the gastrocolic omentum. It is known that carcinoma of the stomach often spreads microscopicaIIy in the adventitia1 Iayers to a greater distance than is removed by the IocaI excision of such an ulcer and of course the Iatter procedure Ieaves a11 the Iymph gIands intact. This reasoning has been reenforced by our knowIedge of severa cases where the surgeon, feeIing defIniteIy
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that the lesion was a benign ulcer, removed it IocaIIy with a generous ehipse of the surrounding gastric waI1 with the a11 too prompt recurrence of the carcinoma Iocally. The exact type of subtota1 gastrectomy is a matter of individua1 preference. We usuaIIy use an end-to-side gastroenterostomy with a Iong jejuna1 Ioop brought anterior to the coIon and so arranged that the greater curvature of the stomach is attached to the jejunum proximaIIy and the Iesser curvature distalIy. This is the Moynihan modification of the PoIya operation and is, in our estimation, ordinariIy more desirabIe for this purpose than the generaIIy adopted BaIfour modification because the latter requires an enteroenterostomy between the two Iimbs of the anastomotic Ioop whiIe the former does not. While the Moynihan-PoIya subtota1 gastrectomy is the one we usuaIIy use, this choice is modified by the physica circumstances found. When there is a short jejuna1 mesentery, or a very heavy omental pannicuIus, the method described by Lahey is frequentIy adopted rather than bringing the jejunal Ioop anterior to the coIon. In this procedure, the first portion of the duodenum is freed at Treitz ligament and is brought up directIy into the Iesser peritonea1 cavity and the jejunum dista1 to the anastomosis passes through the transpIanted mesocolon as a singIe segment rather than a loop. There are numerous other methods of reconstruction after subtota1 gastrectomy which have recentIy been we11 reviewed by Pack.14 No method which does not provide for carefu1 remova of the Iymph gIand-bearing areas wiI1, in our estimation, be uItimateIy acceptabIe. For this reason, the BiIIroth I operation and a11 of its modern modifications are usuahy to be avoided because they frequently limit the amount of the Iesser curvature of the stomach which can be taken and hence prevent the extensive remova of the Iymph gIands aIong the left gastric artery. The guiding principIe in the choice of the technica method is that the procedure shouId be the one which the
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surgeon would chose if he knew the uIcer to be definiteIy carcinomatous. There is one additiona word of warning
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shouId be resorted to promptIy. Some wiI1 indeed prove to be maIignant prepyloric gastric ulcers.
7. Deformity in the pyIoric region. It was impossibIe to determine whether the pylorus was proximal or distal to the invokement. ConsequentIy this patient had an expIoratory Iaparotomy because of the danger of procrastination in the presence of a prepyloric lesion. A duodena1 ulcer was found at operation.
FIG.
that should be given. DuodenaI uicers are practicahy never malignant. However, smaI1 uIcers just proxima1 to the pyIorus may produce a typica roentgenoIogic appearance of the usua1 duodena1 uIcer, namely a constant spastic deformity of the duodena1 cap, without anything to suggest the IocaIization of the lesion on the gastric side. PrepyIoric gastric ulcers, as Hoimes first emphasized, l5 have an increased IikeIihood of maIignancy although there is a controversy about the exact incidence. l6 ConsequentIy, if the lesion cannot be proved to be duodenal by the presence of a niche or the visuaIization of a fleck definiteIy dista1 to the pyIorus, then the possibility of the Iesion being prepyIoric rather than postpyIoric must be borne in mind. If the Iesion is refractory to treatment or if symptoms recur, particuIarIy in the oIder group of patients, exploratory Iaparotomy
F. T. F. is an exceIlent iIlustration of this mistake in diagnosis. The gastrointestinal roentgenoIogic examination showed only a persistant irregularity of the cap with tenderness Iocalized over it. The typical ulcer pain during the day quickIy cIeared up on a Sippy rkgime and the patient was discharged from the hospital though a residua1 night distress stiI1 remained. On an ambuIatory uIcer rCgime, severe pain recurred in two months and on this account the patient was expIored. A smaI1 non-indurated, prepyIoric uIcer was found. The surgeon who was operating was so sure that this could not be maIignant that he carried out IocaI excision with a IiberaI wedge and a posterior gastroenterostomy. On microscopic examination, the ulcer proved to be malignant. The patient was urged to submit to a subtota1 gastrectomy immediateIy, but compIeteIy reIieved of her symptoms, she refused, onIy to return within a year with a Iarge recurrent mahgnant mass in the epigastrium verified by biopsy.
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Sometimes the deformity associated with the Iesion makes it impossibIe to pIace with certainty the position of the pyIorus. Figure 7 iIIustrates such a situation. If the roentgenoIogist is in serious doubt whether the Iesion is proxima1 or dista1 to the pyIorus, then it is wiser to carry out expIoratory Iaparotomy than to procrastinate, possibly in the presence of a prepyIoric uIcer. Each year there come to our attention one or two cases of prepyIoric carcinoma in which the possibility of maIignancy was not considered because the Iesion was diagnosed as a duodena1 uIcer. CONCLUSIONS I. Any chronic gastric uIcer may be carcinomatous. There is no certain clinica or roentgenoIogic differentiation between the two conditions. 2. Symptomatic relief on medica treatment is no assurance that the Iesion is not malignant. 3. The prompt reIief of symptoms, together with a significant decrease in the size of the ulcer niche, is an indication for continuing conservative treatment, but the ulcer must be foIIowed roentgenographicaIIy unti1 compIeteIy heaIed. 4. FaiIure of the uIcer to decrease steadiIy in size or the return of symptoms whiIe on treatment immediateIy makes the Iesion a carcinoma-suspect. 5. UIcers just proxima1 to the pyIorus may produce by x-ray only a constant spastic deformity of the duodena1 cap and hence be diagnosed duodenal uIcers. It is
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important to bear in mind the possibiIity of maIignancy where a supposedIy duodenal uIcer is recalcitrant to treatment. REFERENCES
I. CRUVEILHIER, J. Anatomie pathologique du corps humain. Vol. I. Paris, 1829-1842. J. B. Bailhere. 2. CARMIAN,R. D. A new roentgen-ray sign of utcerating gastric carcinoma. J. A. M. A., 77: ggo, Igtr . 3. CARMAN, R. D. Benign and malignant gastric ulcers from a roentgenologic viewpoint. Am. J. Roentgenol., 8: 695, 1921. 4. ALVAREZ,W. C., and MACCARTY,W. C. The size of resected gastric ulcers and gastric carcinomas. J. A. M. A., 91: 226, 1928. 5. Scorr, W. J. M. The possibihty of malignancy as it affects the treatment of chronic gastric uIcer. Ann. Surg., 102: 586, 1935. 6. GRAHAM,R. R. Carcinoma of the stomach. Canad. M. A. J., 30: 393, 1934. 7. RIVERS. A. B.. and DRY. T. J. Differentiation of benign and maIignant gastric ulcers. Arch. Surg., 30: 702, 1935. 8. SCOTT,W. J. M. The reIationship of carcinoma and cahous gastric ulcer. Surg., Gynec. IY Obst., 46: 109, 1928. 9. JORDAN, S. M. Gastric uIcer and cancer. J. A.M. A., 93: 1642, 1929. LAHEY, F. H. The treatment of gastric and duodena uIcer. J. A. M. A., 95: 313, 1930. IO. &GAL, H. L., and Scorr, W. J. M. Changes and resuIts of a decade in the management of gastric uIcer. Rev. Gastroenterol., 4: IOI, 1937. I I. GRAHAM, R. R. Discussion. Ann. Surg., 102: 603, 1935. 12. JUDD, E. S., and WALDRON, G. W. The present status of the surgica1 treatment of peptic ulcer. Surg., Gynec. e??Obst., 59: 350, 1934. 13. HEUER, G. J. The choice of treatment of peptic ulcer. New York State J. Med., 35: I, 1935. 14. PACK, G. T., and SCHARNAGEL, I. M. The technique of gastric resection for carcinoma. Surg., Gynec. u Obst., 63: 189, 1936. 15. HOLMES, G. W., and HAMPTON,A. 0. Incidence of carcinoma in certain chronic ulcerating Iesions of the stomach. J. A. M. A., gg: 905, 1932. 16. SINGLETON,A. C. Benign prepyIoric uIcer. Radial., 26: 198, 1936.
W
HEN Cruveilhierl. estabhshed tric uIcer as a pathoIogic cIinica1 entity separate from
Fellow in Surgery, University of Rochester Medicine and Dentistry NEW
School of
YORK
differentiated from chronic gastric ulcer certain radioIogic by this means. AIso features of some uIcers are rather patho-
gasand car-
FIG. I. Meniscus sign. Note the Iarge crescentic encroachment on the lumen of the stomach about the centra1 ukeration. This Iesion was a maIignant uIcer occurring on the posterior waI1 of the stomach. The meniscus sign is practicaIIy pathognomonic of maIignancy and usuaIIy has to be obtained with the aid of palpation at fluoroscopy. Dotted Iine indicates the extent of the meniscus.
gnomonic. Thus the meniscus formation about an uIcer (Fig. I) signifies malignancy,2 whiIe the formation of an-accessary pocket by the niche (Fig. 2), is fairIy good evidence that the uIcer at least started as a benign one.3 It was hoped at one time that the size of the uIcer, as reveaIed roentgenoIogicaIIy, might be a good index of its character.4 It is true that the majority of uIcers over 2.5 cm. in diameter are maIignant, whiIe most of the smaI1 uIcers (I to 1.5 cm. in diameter) prove to be benign.
cinema of the stomach, he Iaid the foundation for our modern conception of these two conditions. He mentioned the occasiona1 presence of both Iesions in the same the two conditions organ, but thought could always be differentiated grossIy one from the other. Since then the advent of the roentgenographic examination has enormousIy assisted us in the cIinica1 diagnosis. The usua1 types of scirrhous and papiIIary carcinoma of the stomach are easiIy * From the Department
of Surgery,
the UniversityLRY;fester e 42
SchooI of Medicine and Dentistry,
Rochester,
NEW SERIES VOL. XL, No.
I
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Mider-Malignancy
However, there are so many exceptions to this genera1 ruIe (Fig. 3) that it is aImost vaIueIess as a guide to therapy
in Ulcer
American ~~~~~~~ of surgery
43
other hand, if a11 cases of gastric carcinoma with symptomatic or roentgenographic evidence of uIceration were incIuded in the
FIG. 2. An uIcer with an accessory pocket outside the stomach. As a rule such lesions are benign no matter how large the crater, untess definite characteristics of malignancy are present in the stomach wall adjacent to the uker. This enormous ulcer proved to be benign.
in the individua1 case.5 Other factors, such as the age of the patient, the constancy and duration of symptoms, the Iocation of the uIcer, etc., assist from a statistica basis,6,7 but are inadequate in the individua1 instance for making this differentiation. In the century since Cruveilhier’s time, we have Iearned that there is a lesion with a11 the characteristics of the benign uIcer which proves nevertheIess to be maIignant. The exact frequency of this malignant uIcer which cannot be differentiated either by symptoms, by x-ray examination, or at times even by gross examination, wiI1 vary considerabIy in different series, depending partly on the criteria estabIished by the compiIer. Thus, if every uIcer in the stomach is considered a potentially malignant Iesion, then automaticaIIy a11 Iesions which eventuahy prove to be malignant would be segregated as carcinoma suspects and wouId never appear in the statistics of a group of chronic gastric ulcers. On the
group, the percentage of such chronic malignant ulcers wouId be disproportionateiy high. In the record when the diagnosis eventuaIIy proves to be maIignancy, the preliminary diagnosis of gastric uIcer is discarded and the case is cIassified in the diagnostic file as carcinoma of the stomach. Consequently the onIy method of estimating the percentage of cases, which present themseIves as chronic gastric ulcers but eventuaIly prove to be malignant, is by studying the diagnostic data after carefu1 clinica and roentgenographic study but before the fIna pathoIogic evidence is known. It is, in our opinion, a conservative estimate that, when the incidence is determined in this manner, IO to 20 per cent of the chronic uIcers of the stomach without defmite criteria of malignancy prove eventuaIIy to be or to become maIignant. Whether such uIcers are from the first carcinomatous or whether they represent
44
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a malignant degeneration of a pre-existing benign ulcer has been vigorously debated. This interesting subject has been previousIy
in Ulcer
APRIL. 1938
gastric ulcers there is at present no method of examination, either clinical, chemical or roentgenographic, that will with certainty
FIG. 3. The size of the ulcer crater is no criterion of its malignancy in the individual case. This uIcer on the lesser curvature of the stomach measured 3.8 cm. in diameter. It was resected and proved benign.
FIG. 4. Gastric uIcer Iocated on the Iesser curvature at the incisura angularis. In spite of the immediate compIete relief of symptoms by an ambulatory medical regime, the size of the uIcer was not decreased at the end of three weeks. Hence the Iesion was treated as carcinoma. (Fig. 3 shows the microscopic picture.)
carefuIIy reviewed by one of us. 8 The controversia1 aspects of this question have distracted attention from the important clinica fact; in the majority of chronic
distinguish the mahgnant from Iesions. And yet it is extremeIy to determine this point to give tage of early operation in the
the benign important the advanmalignant
NEW
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se. One sohrtion of the probIem proposed is to operate upon al1 cases ’ t1re surgeon ch ronic gastric uIcer. Another method of
in UIcer
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acteristic, coming two to three hours a fter meats and being relieved by soda, though not so much by food. The bouts of pain had re-
FIG. 3. Same case as in Figure 4. Transition in the mucous membrane from reIatively architecture to definite carcinoma at the edge of the ulcer. (X 100.)
handIing this situation is to ignore the danger of malignancy. Neither of these pIans is acceptabIe today, the first because it entaiIs unnecessary surgery in many cases, the second because it takes away the patient’s best chance for a cure. Its exponents claim for gastroscopy that it is a vaIuabIe adjunct in deciding the character of an ulcer. EventuaIIy this direct visua1 inspection may be very heIpfu1 when the uIcer can be seen but it has not yet sufhciently proved itself. The foIIowing case ihustrates the diIemma of the chronic gastric ulcer and the method we have adopted to meet it. C. W. A., a 62 year oId farmer, was referred the out-patient department of the Strong MemoriaI Hospital on January 31, 1934, complaining of attacks of epigastric pain of seven months’ duration. The pain was fairIy charto
45
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centIy become somewhat more frequent and severe. The patient reported that he did not vomit, but was frequentIy nauseated. He had Iost 15 pounds in weight. On physica examination he appeared rather thin and he had a moderate degree of arteriosclerosis. No masses were paIpabIe in the abdomen, nor was there any tenderness elicited. Examination of the blood and urine proved negative. On gastric anaIysis, he had no free HCI in the fasting sample, but did have thirty minutes after an aIcoho1 test meal. A St001 specimen gave a negative test for occult bIood. On his first visit to the out-patient department a tentative diagnosis of peptic ulcer, unIocaIized, was made from the history and while arrangements for gastrointestinal x-ray studies were being compIeted, he was put upon an ulcer rCgime (ambuIatory smooth), This promptly reIieved his pain and made him quite comfortabIe. The gastrointestina1 series showed
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a fairIy Iarge uIcer nlithe on the Iesser curvature of the stomach just dista1 to the incisura angularis. (Fig. 4.)
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to expIain to him the dangers of the situaltion. With the aid of the brother’s persuasion, the patient fInalIy accepted operation which was
FIG. 6. Carcinoma producing an extensive characteristic fiIIing defect along the greater curvature of the stomach. At the time this x-ray was taken, symptoms were relieved by dietary treatment and the patient gained 25 pounds in weight. The diagnosis was verified later by biopsy of metastases.
As soon as the uIcer was Iocalized in the stomach, he was advised to come into the hospita1 for a period of strict medica rCgime, but, since he had no pain, he refused to foIIow this advice. The importance of repeating the x-ray studies in three weeks time was urged upon him, however. This was done on March 28 and no significant change in the size of the fiIIing defect was found aIthough there had been compIete reIief of symptoms and a gain of IO pounds in weight. As this faiIure of the uIcer to decrease in size placed it in the carcinomasuspect group in spite of the cIinica1 improvement, he was advised to enter the hospital for operation. He refused to accept this advice even on urging. ConsequentIy his brother, a minister, was caIIed from a distance of 400 miIes in order
carried out on ApriI g, 1934. A chronic uIcer was found at the site indicated by the x-ray examination. It was moderateIy indurated but had no characteristics to distinguish it as a malignant uIcer. On microscopic section, however, there was definite infiltration of the ulcer base with carcinomatous ceIIs. (Fig. 5.) Four years after operation this patient is symptom-free without evidence of recurrence. Certain features in the above case emphasize facts of great cIinica1 importance.
In the first pIace, the compIete disappearance of symptoms with a significant gain in weight when the patient is put on a medica rkgime is no evidence whatever
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that the ulcer is benign. In fact, frequentIy the mahgnant gastric Iesion wiI1 respond in this manner even when it presents unmistakable roentgenoIogic evidence of its maIignancy. Figure 6 shows such a frank carcinoma of the stomach producing a Iarge fiIIing defect of the greater curvature. Yet for three months this patient’s symptom of gastric distress was unfortunateIy controIIed by a medica uIcer regime under the care of her IocaI physician whiIe she gained 23 pounds in weight. She was referred for surgery onIy after symptoms had recurred under treatment, a condition which usuaIIy signifies an extension of the maiignant process. Dr. OsIer frequentIy caIIed attention to such temporary improvement on the institution of dietary treatment in gastric carcinoma. In the second pIace, however, the faiIure of the ulcer to decrease significantIy in size after three weeks treatment places it definiteIy as a carcinoma-suspect. Jordan and Laheyg were the first to emphasize the importance of such a response as a criterion of the nature of the ulcer. In our cIinic, a11 gastric uIcers are divided within three weeks into two groups on the basis of their behavior on a strict uIcer regime. lo The first group contains most of the benign uIcers, and is characterized as foIIows: (I) UIcer pain diminishes in the first week. (2) AI1 symptoms and occult bIood in the stool (if present) disappear within two weeks. (3) There is a signijcant decrease in the size of the ulcer niche (at least one-third of its cross-sectional area) within three weeks. If any of these three conditions is not fulfiIIed, the uIcer immediately falIs into the second or carcinomasuspect group. This Iatter contains almost a11 of the carcinomatous ulcers, together with a minority of benign uIcers, which are particuIarIy recaIcitrant to medica treatment (usuaIIy due to an adherence of the uIcer base to the pancreas or Iiver). As previousIy emphasized, malignant uIcers not infrequentIy respond to treatment with symptomatic relief; a few of them wiI1 even give roentgenographic
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evidence of heaIing at the end of three weeks. ConsequentIy it cannot be inferred that the uIcers in the first group are a11 benign uIcers, but onIy that conservative treatment shouId be continued. The ulcer, however, shouid be foIIowed roentgenographicaIIy at intervars of four to six weeks until the niche has compIeteIy disappeared. Then, if symptoms recur on treatment, or if the uIcer after decreasing in size becomes stationary or particuIarIy if it begins to enIarge, this immediateIy transfers the case to the second group and prompt operation becomes imperative. The importance of following this ruie is iIIustrated by the foIIowing case : P. W., a 40 year old man with a somewhat vague previous history of uIcer was admitted with a perforation on December 12, 193 I. It was thought before the first operation that the uIcer was probabIy duodena1, but a free perforation I cm. in diameter without any unusua1 induration about it, was found on the Iesser curvature of the stomach about 2.5 cm. from the pylorus. This was cIosed by inversion and the patient had an uninterrupted convaIescence with symptomatic reIief for about two years. He then had a recurrence of some distress but not sufficient to bring him back to the cIinic unti1 about six weeks Iater when he had a major hemorrhage. presenting cIinicaIIy as meIena with a drop in the red count to 3,500,000. In view of the recurrence of symptoms, however, as soon as he had regenerated a fair proportion of the Iost bIood, operation was carried out on the patient as a carcinoma-suspect. The site of the previous uIcer on the Iesser curvature couId be identified by two encysted bIack siIk sutures on the peritonea1 surface and the lesion was dire&y contiguous to this scar on the posterior surface of the stomach. Due to the extensive induration of the Iesion, it was thought to be a maIignant ulcer and microscopic examination proved it to be such. A subtota1 gastrectomy was carried out which gave the patient compIete reIief for two years, after which he deveIoped metastases to the spine. This is the onIy case that we have had in which free perforation of a non-indurated gastric uIcer has eventuated in a carcinomatous ulcer. Graham” records a most unusua1 case in which he folIowed the heaIing of an uIcer
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niche to complete disappearance with the subsequent recurrence of a malignant ulcer at that site. While such extreme exampIes as these cases are unusua1, the recurrence of symptoms from a gastric uIcer whiIe the patient is on an adequate conservative regime is aIways an ominous sign and at once puts the uIcer in the carcinomasuspect group. The fIna feature, and an extremeIy important one in the management of these uIcers, is the type of surgery to be empIoyed in the second group, which does not respond with satisfactory heaIing to the therapeutic test. Many surgeons fee1 that a IocaI excision of the Iesion (usuaIIy with gastroenterostomy) is satisfactory. Indeed, this is probabIy the prevaiIing opinion, even being heId by some Ieading surgica1 authorities.12q13 However, we are convinced both on a priori reasoning and on the basis of the experience of ourseIves and others that this pIan is absoIuteIy wrong if the patient is a fairIy good surgica1 risk. The majority of the benign gastric uIcers by the pIan outIined never require surgica1 intervention, and most of the group seIected in this manner by their response to the therapeutic test prove to be maIignant. It is impossible to teI1 at operation in this seIected group which wil1 prove to be benign and which maIignant. ConsequentIy we fee1 that the only rationa pIan is to treat the uIcers of this group at operation exactIy as the surgeon wouId if he knew the pathoIogic section showed maIignancy aIready at hand. This means, in our opinion, carrying out subtota1 gastrectomy, incIuding the Iymph gIand-bearing areas aIong the Ieft gastric artery, in the paraduodena1 region, and of the gastrocolic omentum. It is known that carcinoma of the stomach often spreads microscopicaIIy in the adventitia1 Iayers to a greater distance than is removed by the IocaI excision of such an ulcer and of course the Iatter procedure Ieaves a11 the Iymph gIands intact. This reasoning has been reenforced by our knowIedge of severa cases where the surgeon, feeIing defIniteIy
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that the lesion was a benign ulcer, removed it IocaIIy with a generous ehipse of the surrounding gastric waI1 with the a11 too prompt recurrence of the carcinoma Iocally. The exact type of subtota1 gastrectomy is a matter of individua1 preference. We usuaIIy use an end-to-side gastroenterostomy with a Iong jejuna1 Ioop brought anterior to the coIon and so arranged that the greater curvature of the stomach is attached to the jejunum proximaIIy and the Iesser curvature distalIy. This is the Moynihan modification of the PoIya operation and is, in our estimation, ordinariIy more desirabIe for this purpose than the generaIIy adopted BaIfour modification because the latter requires an enteroenterostomy between the two Iimbs of the anastomotic Ioop whiIe the former does not. While the Moynihan-PoIya subtota1 gastrectomy is the one we usuaIIy use, this choice is modified by the physica circumstances found. When there is a short jejuna1 mesentery, or a very heavy omental pannicuIus, the method described by Lahey is frequentIy adopted rather than bringing the jejunal Ioop anterior to the coIon. In this procedure, the first portion of the duodenum is freed at Treitz ligament and is brought up directIy into the Iesser peritonea1 cavity and the jejunum dista1 to the anastomosis passes through the transpIanted mesocolon as a singIe segment rather than a loop. There are numerous other methods of reconstruction after subtota1 gastrectomy which have recentIy been we11 reviewed by Pack.14 No method which does not provide for carefu1 remova of the Iymph gIand-bearing areas wiI1, in our estimation, be uItimateIy acceptabIe. For this reason, the BiIIroth I operation and a11 of its modern modifications are usuahy to be avoided because they frequently limit the amount of the Iesser curvature of the stomach which can be taken and hence prevent the extensive remova of the Iymph gIands aIong the left gastric artery. The guiding principIe in the choice of the technica method is that the procedure shouId be the one which the
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surgeon would chose if he knew the uIcer to be definiteIy carcinomatous. There is one additiona word of warning
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shouId be resorted to promptIy. Some wiI1 indeed prove to be maIignant prepyloric gastric ulcers.
7. Deformity in the pyIoric region. It was impossibIe to determine whether the pylorus was proximal or distal to the invokement. ConsequentIy this patient had an expIoratory Iaparotomy because of the danger of procrastination in the presence of a prepyloric lesion. A duodena1 ulcer was found at operation.
FIG.
that should be given. DuodenaI uicers are practicahy never malignant. However, smaI1 uIcers just proxima1 to the pyIorus may produce a typica roentgenoIogic appearance of the usua1 duodena1 uIcer, namely a constant spastic deformity of the duodena1 cap, without anything to suggest the IocaIization of the lesion on the gastric side. PrepyIoric gastric ulcers, as Hoimes first emphasized, l5 have an increased IikeIihood of maIignancy although there is a controversy about the exact incidence. l6 ConsequentIy, if the lesion cannot be proved to be duodenal by the presence of a niche or the visuaIization of a fleck definiteIy dista1 to the pyIorus, then the possibility of the Iesion being prepyIoric rather than postpyIoric must be borne in mind. If the Iesion is refractory to treatment or if symptoms recur, particuIarIy in the oIder group of patients, exploratory Iaparotomy
F. T. F. is an exceIlent iIlustration of this mistake in diagnosis. The gastrointestinal roentgenoIogic examination showed only a persistant irregularity of the cap with tenderness Iocalized over it. The typical ulcer pain during the day quickIy cIeared up on a Sippy rkgime and the patient was discharged from the hospital though a residua1 night distress stiI1 remained. On an ambuIatory uIcer rCgime, severe pain recurred in two months and on this account the patient was expIored. A smaI1 non-indurated, prepyIoric uIcer was found. The surgeon who was operating was so sure that this could not be maIignant that he carried out IocaI excision with a IiberaI wedge and a posterior gastroenterostomy. On microscopic examination, the ulcer proved to be malignant. The patient was urged to submit to a subtota1 gastrectomy immediateIy, but compIeteIy reIieved of her symptoms, she refused, onIy to return within a year with a Iarge recurrent mahgnant mass in the epigastrium verified by biopsy.
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Sometimes the deformity associated with the Iesion makes it impossibIe to pIace with certainty the position of the pyIorus. Figure 7 iIIustrates such a situation. If the roentgenoIogist is in serious doubt whether the Iesion is proxima1 or dista1 to the pyIorus, then it is wiser to carry out expIoratory Iaparotomy than to procrastinate, possibly in the presence of a prepyIoric uIcer. Each year there come to our attention one or two cases of prepyIoric carcinoma in which the possibility of maIignancy was not considered because the Iesion was diagnosed as a duodena1 uIcer. CONCLUSIONS I. Any chronic gastric uIcer may be carcinomatous. There is no certain clinica or roentgenoIogic differentiation between the two conditions. 2. Symptomatic relief on medica treatment is no assurance that the Iesion is not malignant. 3. The prompt reIief of symptoms, together with a significant decrease in the size of the ulcer niche, is an indication for continuing conservative treatment, but the ulcer must be foIIowed roentgenographicaIIy unti1 compIeteIy heaIed. 4. FaiIure of the uIcer to decrease steadiIy in size or the return of symptoms whiIe on treatment immediateIy makes the Iesion a carcinoma-suspect. 5. UIcers just proxima1 to the pyIorus may produce by x-ray only a constant spastic deformity of the duodena1 cap and hence be diagnosed duodenal uIcers. It is
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important to bear in mind the possibiIity of maIignancy where a supposedIy duodenal uIcer is recalcitrant to treatment. REFERENCES
I. CRUVEILHIER, J. Anatomie pathologique du corps humain. Vol. I. Paris, 1829-1842. J. B. Bailhere. 2. CARMIAN,R. D. A new roentgen-ray sign of utcerating gastric carcinoma. J. A. M. A., 77: ggo, Igtr . 3. CARMAN, R. D. Benign and malignant gastric ulcers from a roentgenologic viewpoint. Am. J. Roentgenol., 8: 695, 1921. 4. ALVAREZ,W. C., and MACCARTY,W. C. The size of resected gastric ulcers and gastric carcinomas. J. A. M. A., 91: 226, 1928. 5. Scorr, W. J. M. The possibihty of malignancy as it affects the treatment of chronic gastric uIcer. Ann. Surg., 102: 586, 1935. 6. GRAHAM,R. R. Carcinoma of the stomach. Canad. M. A. J., 30: 393, 1934. 7. RIVERS. A. B.. and DRY. T. J. Differentiation of benign and maIignant gastric ulcers. Arch. Surg., 30: 702, 1935. 8. SCOTT,W. J. M. The reIationship of carcinoma and cahous gastric ulcer. Surg., Gynec. IY Obst., 46: 109, 1928. 9. JORDAN, S. M. Gastric uIcer and cancer. J. A.M. A., 93: 1642, 1929. LAHEY, F. H. The treatment of gastric and duodena uIcer. J. A. M. A., 95: 313, 1930. IO. &GAL, H. L., and Scorr, W. J. M. Changes and resuIts of a decade in the management of gastric uIcer. Rev. Gastroenterol., 4: IOI, 1937. I I. GRAHAM, R. R. Discussion. Ann. Surg., 102: 603, 1935. 12. JUDD, E. S., and WALDRON, G. W. The present status of the surgica1 treatment of peptic ulcer. Surg., Gynec. e??Obst., 59: 350, 1934. 13. HEUER, G. J. The choice of treatment of peptic ulcer. New York State J. Med., 35: I, 1935. 14. PACK, G. T., and SCHARNAGEL, I. M. The technique of gastric resection for carcinoma. Surg., Gynec. u Obst., 63: 189, 1936. 15. HOLMES, G. W., and HAMPTON,A. 0. Incidence of carcinoma in certain chronic ulcerating Iesions of the stomach. J. A. M. A., gg: 905, 1932. 16. SINGLETON,A. C. Benign prepyIoric uIcer. Radial., 26: 198, 1936.